business man sitting at a cafe discussing his health options on his cell phone

I Missed Open Enrollment and Need Health Coverage — What Are My Options?

The next official ACA Open Enrollment period isn’t slated to begin until November 1, 2019. But depending on your circumstances, you may not have to wait that long to obtain coverage.

Qualifying Life Events and Special Enrollment Periods

Sometimes our circumstances change, and if they change due to specific events, you and your dependents may be able to secure health insurance through a Special Enrollment Period. When this occurs, it is called a Qualifying Life Event, otherwise referred to as a QLE.

There are several types of Qualifying Life Events that may grant you a Special Enrollment Period. Some of the most common examples include:

  • Loss of health coverage
    • Losing existing health coverage – including job-based, individual, and student plans
    • Losing eligibility for Medicare, Medicaid, or CHIP
    • Turning 26 and losing coverage through a parent’s plan
  • Changes in household size
    • Getting married or divorced
    • Having a baby or adopting a child
    • Death in the family
  • Changes in residence
    • Moving to a different ZIP code or county
    • A student moving to or from the place they attend school
    • A seasonal worker moving to or from the place they both live and work
    • Moving to or from a shelter or other transitional housing
  • Other qualifying events
    • Changes in your income that affect the coverage you qualify for
    • Gaining membership in a federally recognized tribe, or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
    • Becoming a U.S. citizen
    • Leaving incarceration (jail or prison)
    • AmeriCorps members starting or ending their service

Non-ACA Health Plans

Haven’t experienced a QLE but still need health coverage? A non-ACA health plan could be the answer. Also referred to as Short Term Medical Plans, recent legislative changes have loosened the restrictions surrounding these plans and have increased their appeal.

Previously, a Short-Term Medical plan could only provide coverage for up to 90 days. But due to recent regulatory changes, these plans can now be continued for up to a year.  Additionally, in some cases applicants may now renew their plan for up to three years.

Because Short-Term Medical Plans are considered non-ACA health plans, it is worth noting that they may not cover all that an ACA health plan would. For example, applicants could be denied coverage due to a pre-existing medical condition, maternity care may not be covered, and there could be an annual dollar limit on coverage. However, these plans are also typically less expensive than ACA plans and could be a good alternative for individuals seeking more affordable options.

Know Your Options

Do you think you may qualify for a Special Enrollment period? Are you interested in hearing more about non-ACA plans and if they may be the right fit for you? Our Benefits Counselors are always on hand to help answer your questions and guide you in the direction that will make the most sense for your unique needs.

Visit your association website to learn more about the Health Insurance offerings that may be available to you, or schedule an appointment with one of our licensed Benefits Counselors today.

grandfather blowing out birthday cake candles at a birthday party with family

Waiting to Enroll in a Medigap Policy Could Cost You

Throughout our lives, we have a number of birthdays but only a few age milestones ever really stand out—thirteen, sixteen, eighteen, twenty-one, forty, and sixty-five. The milestones get fewer as we age, but few are as important as the final one.

If you or someone you love is soon to turn 65, there are a number of things to start to consider. While the potential for retirement is one, another really big decision to make is how much, or how little insurance you will need.

Three months prior to turning 65, you become eligible to sign up for Medicare.  Once you review your options and make your selections between Part A, B, C, and D you must then decide if these plan benefits will be enough for you.

About Medicare Supplemental Insurance (Medigap)

For those who feel they need additional coverage and benefits, supplemental Medicare insurance (otherwise known as Medigap Supplement Plans) is there to help offset any additional costs you may not have foreseen when you originally signed up for Medicare. In fact, Medicare Supplemental Insurance is sometimes called Medigap coverage because it helps to fill in the gaps in coverage that Medicare can sometimes leave behind.

Your open enrollment eligibility to sign up for one of these policies begins on the day your turn 65 and are covered under Medicare Part B. To be eligible to sign up for a Medigap policy, you must be covered under Parts A and B of Medicare.

Your open enrollment period ends six months after your 65th birthday. So what happens then? What happens if you choose to not sign up for a Medigap policy within that specific time frame but still wish to purchase it?

The simple truth of it is, you may not be able to. In the event you are able to purchase a Medigap policy in your state after the initial six-month-period of open enrollment eligibility, it may cost you a great deal more than you were originally quoted to secure the same coverage you would have gotten if you had signed up immediately following your 65th birthday. In short, there are no positives to waiting to secure a Medigap Supplemental Insurance.

Why Buy Medigap coverage?

Medicare Parts A and Part B do not offer you 100% medical coverage from the age of 65 on. While Medicare does cover a great deal of expenses that could otherwise be quite costly and stressful, it does not cover everything.

According to Medicare.gov, Medicare Parts A and B fail to cover the following:

  • Long-term care
  • Prescription drugs (Medicare Part D helps cover this)
  • Most dental care services
  • Eye exams pertaining to eyeglasses
  • Cosmetic surgery
  • Acupuncture
  • The vast majority of Chiropractic services
  • Exams and fittings related to hearing aids
  • Routine foot care, not including injuries where a podiatrist might be necessary

For many, Medicare Part A is free and is designed to help enrollees pay for inpatient services, however, according to Medicare.gov, enrollees have a $1,316 hospital inpatient deductible for each benefit period.

While Medigap will not assist enrollees in paying for long-term care, it will assist with coinsurance, deductibles, copays, and serious vision issues such as cataracts surgery which can all greatly help senior citizens looking to minimize their out-of-pocket medical expenses.

For more information on Medicare Supplemental Insurance (Medigap) and what it can do for you or someone you love, please visit https://spark.memberbenefits.com/medicare-supplement/.

mother with breast cancer smiling and hugging her young daughter

What You Should Know: Home Breast Cancer DNA Tests

In March of this year, ancestry DNA testing giant, 23andMe, announced that they would begin testing user DNA for Breast Cancer genes, more specifically identified as the BRCA1 and BRCA2 genes. While technically able to test for these genes for years, it wasn’t until this past March that the FDA officially signed off on it, therefore, making the 23andMe at-home DNA test, the first FDA-approved direct-to-consumer test to evaluate one’s potential risk for cancer.

What Can Your DNA Reveal

The test is offered as an add-on to 23andMe’s standard ancestry report for a total of $199 and is delivered alongside a variety of other reports designed to tell you if you possess certain genetic markers which may suggest a predisposition to things such as:

  • Macular Degeneration
  • Lung and/or Liver Disease
  • Celiac Disease
  • Hemochromatosis
  • Hereditary Thrombophilia
  • Alzheimer’s Disease
  • Parkinson’s, and many more
Read More »
Millennials with tech devices in front of them on a blue bench

Myopia and Millennials: The Trend No One Saw Coming

According to a Nielson Company audience report, it is estimated that the average American spends over 10 hours behind a screen consuming digital media and content. But is this much screen time actually helping us or hurting us?

As it happens, a number of studies have recently come out against the rapid increase in screen time for everyone from toddlers to senior citizens. In fact, some of these studies have shown a correlation between increased screen time and the following:

Read More »
mother and child practicing good dental hygiene in bathroom

The Cost Of Not Having Dental Insurance

If you and your family have been skipping trips to the dentist, you’re not alone. “For every adult without health insurance, an estimated three lack dental insurance” this comes according to a quote issued by the Kaiser Family Foundation based off of research conducted by the National Association of Dental Plans.

A Key Component Of Overall Health and Hygiene

But what so few realize is the close relationship between one’s oral health and their overall health. A person’s mouth is a haven for potentially harmful bacteria, regular flossing, brushing, and cleanings can keep the bacteria at bay but when a person is neglecting their teeth, the bacteria can build and lead to infections, tooth decay, and gum disease. From there, it is possible for the bacteria to enter the bloodstream and travel to other parts of the body leading to other serious problems.

Read More »

Visit a Dentist— ANY Dentist

The Member Group Comprehensive PPO is a dental plan that can help you save1 and get the care you need.

No matter who your dentist may be, with the MetLife Preferred Dentist Program, the power to choose and save is yours.

Here are the facts:

  • You can go to any licensed dentist, in or out of the network.
  • Reimbursement for your out-of-network dental care is based on the 90th percentile of “reasonable and customary” charges1. We look at what dentists in your area actually charge for services, and we calculate reimbursement based on the 90th percentile of those charges.
  • The way we determine allowable charges for the 90th R&C means your eligible benefit amount for out-of-network care is high relative to average dental charges in the community. This helps you pay less out of pocket.
  • Sometimes when you visit an out-of-network dentist you may have to pay part of the bill. This is called balance billing. But with a 90th percentile R&C plan, in most cases, you won’t be balance billed above your typical out-of-pocket costs – your deductible, coinsurance amount, and your plan maximum.

Take charge of your dental care

Talk to your dentist

Before you get any major dental work, you should talk to your dentist about getting a pretreatment estimate2. That’s when your dentist sends the plan for your care to MetLife.

For most procedures, you and your dentists will receive the estimate – online or by fax – during your visit. The statement shows amounts for what your plan covers. Then you and your dentist can talk about your care and costs before your treatment. It’s a great way to be prepared and plan ahead.

Get your plan information – fast!

Managing your dental benefits has never been easier. You’ve got MyBenefits – your secure member website. Just log on at www.metlife.com/mybenefits. With the 24/7 website you can3:

  • Review your plan information, including what’s covered and coinsurance
  • Track your deductible and plan maximums
  • Find a dentist or view your claim history
  • Read up on the oral health information you need to make informed decisions about your care

Take a look at the charts below. They will give you a better idea of how your plan works when you visit a participating (in-network) or a non-participating (out-of-network) dentist.

The 90th bar

This chart shows how often plan members across the nation usually go to a participating or non-participating dentist. It also shows just how rare it is for you to pay more than your typical out-of-pocket costs.

Savings example

This hypothetical example shows that whether you get a cleaning from a participating or non-participating dentist, you can still save money4.

Visit any licensed dentist. The choice is all yours!

Like most group benefit programs, benefit programs offered by MetLife and its affiliates contain certain exclusions, exceptions, waiting periods, reductions of benefits, limitations, and terms for keeping them in force. Please contact MetLife or your Plan Administrator for complete details.

For more information, please click here.

1R&C fee refers to the Reasonable and Customary (R&C) charge, which is based on the lowest of 1) the dentist’s actual charge, 2) the dentist’s usual charge for the

same or similar services or the usual charge of most dentists in the same geographic area for the same or similar services as determined by MetLife.

2Actual benefit determinations are made when services are rendered and are subject to the following as applicable on the date of service: patient eligibility; plan and frequency limitations; maximums and deductibles; and other coverages.

3With the exception of scheduled or unscheduled systems maintenance or interruptions, the MyBenefits website is typically available 24 hours a day, 7 days a week.

4Please note: This is a hypothetical example that reviews an adult teeth cleaning (D1110) in the Chicago area, zip 60601.  It assumes that the annual deductible has been met.

5This example excludes non-participating dentists who charge more than what 90% of what other dentists in the area charge. Please note that if you receive care from a dentist that falls into this category, your out-of-pocket costs may be higher.

6Negotiated Fee refers to the fees that in-network dentists have agreed to accept as payment in full, subject to any co-payments, deductibles, cost sharing and benefits maximums.

Young People Discussing Group Insurance Benefits with an agent

3 Benefits of Group Health Insurance For Employers

Group Health Insurance is usually provided by an employer and can cover just the employee or even the employee’s spouse and children.

Not providing group health coverage could be a major misstep for some companies regardless of size, as there are a number of benefits to providing Group Health Insurance coverage.

1. Lower Costs Than Individual Plans

There is no question that the term health care reform has been a hot-button topic and on the lips of nearly every politician regardless of political party over the course of the past 10 years. In light of the Affordable Care Act (ACA), it has now become more affordable to purchase Group Health Insurance than for your employees to purchase health insurance individually.

Level-funding insurance plan options have been growing in popularity over the past number years. Level-funded plans are ERISA compliant and may offer more flexibility for employers with virtually no risk and offered by several reputable insurance carriers with a nationwide network of hospitals and physicians to choose from.

What has many employers especially excited about these plans is the opportunity for 10%-15% in lower premium costs and the Return of Premium potential. Unlike other policies on the market, with level-funded options, if your employees don’t rack up a large number of claims throughout the year, your company may have a substantial amount of money (originally paid in premiums) returned.

Read More »
elderly man surrounded by happy family

The Unexpected Costs of Medicare

For many patients, Medicare is incredibly helpful. It reduces overall procedure costs, and it can lower prescription costs. However, specialized treatment, unaccounted for fees and hidden procedural requirements may add extra costs you weren’t expecting. If you are on Medicare, be sure to understand the hidden costs, and consider adding a Medicare Supplement policy to cover what Medicare doesn’t.

What is Medicare?

Medicare is the government’s health insurance program. It covers people over 65 years old, young people with disabilities and those with End-Stage Renal Disease. The Medicare program exists across four “parts”, titled Part A, Part B, Part C and Part D. Each part offers coverage for different costs, including:

  • Hospital insurance
  • Medical insurance
  • Medicare Advantage Plans
  • Prescription drug coverage

Unexpected Medicare Costs

While Medicare may seem comprehensive, its wide-ranging brackets fail to reveal several costs. In a recent article, U.S News Health revealed that Medicare Part A requires beneficiaries to pay the following expenses in the event of a hospital stay:

$1,260 for their first 60 days of stay.
Over $315 per day after two months of stay.

Additionally, Medicare’s Part B utilizes a payment regimen based upon monthly premiums, and many individuals may experience payments. If an individual’s income is lower than $85,000 per year, Part B premiums are instituted at approximately $147 per month.

What Doesn’t Medicare Cover?

Patients may be surprised to discover a variety of medical provisions not covered by Medicare. While the system does, in fact, cover many preventative and necessary procedures, visits and treatments, it doesn’t cover a slew other options.

In fact, supplemental coverage is vital when trying to save money where Medicare is considered. Those without supplemental coverage will end up paying expenses out of pocket, and they’ll pay full prices, even with Medicare’s attachments.

While Medicare can assist a patient’s procedures and costs, it doesn’t cover certain areas. Unfortunately, patients may be unaware of Medicare’s “coverage end-zone”. For example, the following medical provisions are not covered through Medicare Parts A through D, and must be covered separately:

  • Eye exams
  • Eyeglasses
  • Hearing aids
  • Hearing exams
  • Cosmetic surgery
  • Dental care

Additionally, several routine procedures aren’t covered by Medicare provisions. In essence, Medicare serves public patients through intensive treatments, prescription insurance, and hospital stays. However, diagnostic treatments, remedial therapy, and even hospital-based amenities may not be covered.

Does Medicare Supplement Insurance Help With Uncovered Balances?

Yes. In fact, Medicare Supplement Insurance is commonly called “Medigap” by private companies because it fills the “gap” in coverage that Medicare leaves. It helps with coinsurance, copayments, deductibles and other healthcare costs. Many people experience difficulties with full Medicare coverage, but Medicare Supplement Insurance can help.

If you’re eligible for Medicare benefits, or if you’re close to fulfilling Medicare requirements, visit the Spark Health Insurance Marketplace to review your Medicare Supplement Insurance options.

1 2 3 4 5